Kenya: Rethink Male Cut Campaign in the War Against Aids

Obare Onyango

As debate on whether circumcision reduces the risk of HIV infection or not rages, it is amazing how each side of the divide is getting carried away by emotions to the extent of losing sight of the available evidence.

This reminds me of the saying that "a good slogan can stop analysis for years".

It is true that there is evidence that HIV prevalence is lower among communities that practise male circumcision than among those that do not.

But there is also evidence to the contrary: that HIV prevalence is higher among communities that practice male circumcision than among those that do not.

This sounds somehow confusing, one would say. But in a nutshell, it shows that the evidence on whether male circumcision protects one against HIV infection is mixed.

Unfortunately, both the proponents and the opponents of the protective role of male circumcision have refused to soberly confront this reality, and thus think through an appropriate prevention strategy.

Since so much has been said about studies that show the protective role of male circumcision, I'll talk about the evidence that shows the contrary.

Two datasets from Malawi (the 2004 Malawi Demographic and Health Survey (MDHS) and the 2004 and 2006 Malawi Diffusion and Ideational Change Project (MDICP)) show that HIV prevalence was highest in the Southern region than in the Central or Northern regions.

Yet, a higher proportion of men from the Southern region, compared to those from the other regions, reported having been circumcised.

In contrast, individuals from the other regions were less likely to report multiple life-time sexual partners than those from the Southern region.

They were also more likely to report condom use during the 12 months preceding the survey than those from the Southern region.

At the individual level, HIV prevalence was higher among circumcised than among uncircumcised men. Among circumcised men, those who were HIV-positive were more likely to report multiple life-time sexual partners than their HIV-negative counterparts.

Similarly, among married women with circumcised husbands, HIV prevalence was higher among those whose spouses reported multiple life-time sexual partners than among their counterparts whose spouses reported one life-time sexual partner.

At a recent meeting when I started engaging a fellow participant on this exceptional evidence from Malawi, she got carried away and branded me a circumcision-basher. [Is circumcision some tender pet or victim whose feelings we ought to respect?]

She did not even stop to listen to what I had to say. Yet, my intention was to see whether, given the two sets of contrasting evidence, we could think through a better way of confronting the HIV and Aids scourge.

I was surprised at how low some scholars have sunk, to the extent of reducing the debate to "us versus them". It left me wondering how the so-called circumcision-bashers refer to those on the other side of the divide.

To set the records straight, I am not a circumcision-basher, if this refers to male circumcision (female genital cutting is a different matter altogether).

In any case, HIV and Aids should concern everyone and any effort aimed at combating it is laudable.

However, aware of the two sets of contrasting evidence, my concern has always been the manner in which male circumcision is being presented to the public, as if it is the ultimate method of protection against HIV infection.

In my view, the promotion of male circumcision should be accompanied by riders encouraging people to use other means of protection even after the cut.

Otherwise we run the risk of creating the false impression that once a man is circumcised, he can start sleeping around without any care in this world.

Given the evidence from Malawi, one can only shudder at what this might lead to. The Malawi exception also brings into focus the issue of the position of the woman.

It suggests that we can circumcise the men alright, but as long as they remain promiscuous and do not use any protection, their women are still at risk. The question then is, how do we protect the women?

It is against this backdrop that a new way of thinking has started gaining ground within programme circles, what is known in programme parlance as MC-plus (Male Circumcision plus other preventive methods). Isn't this what we ought to be promoting?

[No, not in view of the objections about disempowering women or the risks of circumcision itself.

Nor does it address the costs, in money, resources and skill, of promoting circumcision - which as he says, may be much less effective than its promoters claim - at the expense of other, more effective methods of prevention. ]

Nyanza men rush to hospital for circumcision

The number of men seeking circumcision in Nyanza has increased by 60 per cent.

The rush for the cut began on Monday after researchers tabled evidence at a conference in Kisumu, showing that male circumcision reduced HIV infections by 60 per cent.

On Tuesday, a senior surgeon at the Nyanza Provincial Hospital Otieno Obondi said with the 60 per cent increase in number of those seeking the operation the drive could be disastrous, unless the campaigners worked closely with surgeons.

Queues are growing and health workers are calling for provision of more surgical facilities as the number of men seeking circumcision soared in Kisumu.

A day after Prime Minister Raila Odinga launched a campaign to have Luo men circumcised to help contain the spread of HIV, several people reported to local health facilities for the cut.

Fragile issue

"This is a fragile surgical issue and not a socio-cultural and political matter as some people may perceive it. It is the surgeons and hospital staff who will ensure the safety of the patients," Obondi said.

He added: "It is not how many people are circumcised but how safe they will be after undergoing the operation."

Private hospitals charge Sh2, 000 per operation while the fees is lower in Government hospitals.

Some NGOs are carrying out the exercise free of charge. Others even give incentives for those brave enough to face the knife.

Obondi said there was a risk of many people, especially those in the rural areas, turning to quacks for the cut.

"We must plan for the post-operation care and that is why surgeons must be involved in the campaign," he added.

Obondi disclosed they were handling between six to ten cases a day. [Is this fast enough to halt the epidemic - even if it works? How many new transmissions are there in a day? Are they even keeping up?]

A spot check by The Standard found many young people queuing to be circumcised at the Lumumba Health Centre and other hospitals.

Mr Kennedy Onyango, found on the queue at Lumumba health centre said his girlfriend had given him a condition to face the knife or they split. Obondi said some NGOs might attempt to turn their offices into circumcision centres to attract funding.
Personal decision

While launching the Voluntary Male Circumcision campaign in Kisumu on Monday, Raila said the issue was not communal, but a personal issue.
He said male cut would not erode the community’s cultural heritage as it was purely a medical issue and should not be entangled in cultural politics.

Prof Kawango Agot of the Nyanza Reproductive Health Society disclosed that 15 per cent of uncircumcised men were at a higher risk of contracting HIV than those cut.

[What can that mean? Which 15%? How much higher risk? If it is true, then 85% of uncircumcised men are NOT at higher risk of contracting HIV than those cut - maybe even lower risk.]
...

Kenyan PM, sexually inactive elder brother, Hon Oburu Odinga (aged 66) to be a “guinea pig” for controversial HIV male circumcision? “We have resolved today that we embrace the male cut, but that it remains voluntary. No one will be coerced to go for it,” says Raila

by Editor in Nyanza
By John Oywa and Kepher Otieno

Prime Minister Raila Odinga has launched a massive campaign to rally Luo men to face the knife as part of a strategy to fight HIV/Aids, with two ministers heeding his call.

Finance Assistant minister Oburu Oginga and his Education counterpart Ayiecho Olweny said they would be circumcised next week to bolster the campaign.
...

Female circumcision common in Egypt despite ban

OLD habits, however brutal, die hard. It's six years since Egypt banned female genital mutilation but still it continues. And FGM is unlikely to stop as long as religious leaders condone it and parents believe their daughters will otherwise be disadvantaged.
...

Doctors divided on circumcision

Written by Paul Mulholland

Long hospital waiting lists are the reality for many who request ‘cultural’ circumcisions

The death of a 29-day-old Nigerian baby in Waterford in 2004 as a result of a botched circumcision brought attention to the procedure which was increasingly taking place in immigrant communities around the country.The culture of ‘backstreet circumcisions,’ which were being performed by untrained personnel outside the remit of the health service for religious or cultural reasons, was suddenly on the front pages and the focus of national attention.
...

Man Sues Over Genital Amputation

LOUISVILLE, Ky. (AP) - A Kentucky man who claims his penis was removed without his consent during what was supposed to be a circumcision has sued the doctor who performed the surgery.

A Kentucky may is suing a doctor who he says was only supposed to give him a circumcision, but instead removed his penis.

Phillip Seaton, 61, and his wife are seeking unspecified compensation from Dr. John M. Patterson and the medical practice that performed the circumcision for "loss of service, love and affection." The Seatons also are seeking unspecified punitive damages from Patterson and the medical practice, Commonwealth Urology.

A woman who answered the phone at Commonwealth Urology would not take a message for the doctor Thursday. But the Seaton's attorney said the doctor's post-surgical notes show the doctor thought he detected cancer and removed the penis. Attorney Kevin George said a later test did detect cancer.

"It was not an emergency," George told The Associated Press on Thursday. "It didn't have to happen that way." Seaton was having the procedure on Oct. 19, 2007, to better treat inflammation.

The lawsuit filed earlier this month in state court claims Patterson removed Seaton's penis without consulting either Phillip or Deborah Seaton, or giving them an opportunity to seek a second opinion.

The couple also sued the anesthesiologist, Dr. Oliver James of Shelbyville, claiming he used a general anesthesia even though Seaton asked that it not be administered.

A message left at Commonwealth Urology's corporate office in Lexington was not immediately returned Thursday. A message left for James also was not immediately returned.

...

[It doesn't say what the circumcision was for. Did he even need it? On the other hand, this story strains credulity: a penectomy is a much more serious operation than a circumcision - would the nurses even have the right trays of instruments ready?]

Mbalula flees circumcision

Controversial ANC bigwig Fikile Mbalula put up a desperate fight when he discovered he was about to be circumcised last week.

Mbalula made for the hills, even managing to flag down a taxi to make his escape. But he eventually decided to stay, after talking to a traditional surgeon.

The surgeon, 73-year-old Ruben Nqabeni, said former ANC chief whip Tony Yengeni phoned him last Saturday to say “they had a problem” and they needed help.

Yengeni apparently drove to the traditional surgeon’s house in Guguletu, near Cape Town, that afternoon with an unsuspecting Mbalula, 36, — with ANC provincial secretary Mcebisi Skwatsha following in his car.

Yengeni left Mbalula, in the car while he discussed circumcising Mbalula with Nqabeni. Yengeni said Mbalula was willing to go through with the ritual, but kept on postponing it.

“Then Mbalula walked into the house and asked what was happening. I jokingly asked him when was he going to undergo the ritual and he replied in December. I said: ‘But you’re so old’. And we all laughed,” said Nqabeni.

Matters turned more serious when Mbalula, who was due to fly home to Johannesburg later that day, was informed he was going to the bush. He made a run for it.

Nqabeni said Mbalula managed to flag down a taxi in an attempt to escape, but was eventually persuaded to stay.

A special hut was built for Mbalula to keep prying eyes away and several bodyguards had been deployed to keep watch, Nqabeni confirmed.

Family spokesman Zizi Kodwa denied Mbalula had been duped into “becoming a man”.

He claimed Mbalula had been willing to undergo the ritual for the past four years.

He said Mbalula had expressed an interest in being circumcised when he had been deployed to the Western Cape last month along with Mpumalanga provincial MEC Dina Pule to unite the ANC’s warring factions.

“As a boy going to the mountain, he wouldn’t know what to do, there are things that need to be done. He obviously had spoken to a number of people in the Western Cape that may include (Yengeni and Skwatsha) but it is not them who facilitated everything. They could have been part of the people who handled it,” he said.

ANC heavyweight Mnyamezeli Booi said chiefs from the amaMpondomise — Mbalula’s clan — had sent a delegation to visit him.

Nqabeni said he had been circumcising initiates for more than 40 years — many of whom had gone on to become politicians. These include Yengeni and, now, Mbalula.

“I have to take care of him myself because he is not an ordinary initiate,” said Nqabeni.

Chief Ngangomhlaba Matanzima, chairman of the house of traditional leaders of the Eastern Cape said circumcision was a rite of passage that no one should avoid for the sake of their families and children.

“Circumcision is not only about the operation by the surgeon. It goes with the teachings one receives while there,” he said.

Matanzima said he commended those who decide to undergo the ritual “however old he might be”.

He said in traditional royal houses, uncircumcised men may not assume leadership roles and may not even take a wife.

Mid-life initiation 'sets an example to leaders'

THE decision of former African National Congress Youth League (ANCYL) president Fikile Mbalula to undergo circumcision at the age of 37 set an example to other leaders in similar situations, a prominent traditional leader said yesterday .

Mbalula, a member of the ANC national executive committee, is currently undergoing the Xhosa rite of manhood at a site near Cape Town.

Phathekile Holomisa, who heads the Congress of Traditional Leaders of South Africa, said Mbalula’s decision was to be highly commended.

He said the ritual was normally performed at the age of 18 when a boy began the advance into maturity and could grasp the teachings and words of wisdom imparted to him by elders.

“Mbalula’s deed, however, proves the adage that it is never too late to mend. He has set an example to be followed by others holding positions of leadership and authority who may be in a situation similar to his on the eve of his initiation,” Holomisa said.

With freedom having been achieved in South Africa, its people no longer had an excuse to justify the abandonment of value systems.

[How's that again?]

He said many of those involved in the liberation struggle were forced into the underground, into exile and jail. They were thus denied the opportunity to go through “the normal stages attendant to the growth of youngsters” in accordance with their cultures.

African Editors agree on circumcision training

BY THULANI THWALA

JOHANNESBURG- There is a need to train editors on matters of male circumcision and other HIV/AIDS related issues.

This was the consensus of editors themselves during a one-day dialogue on male circumcision held at the Protea Hotel on Monday. The dialogue, funded by UNICEF and UNAIDS, was attended by editors from various African countries.

Countries that had representative at the dialogue included Swaziland, South Africa, Kenya, Ghana, Uganda, Botswana and other high-ranking officials from organisations like MISA and PANOS.

The dialogue brought together 25 editors and senior media professionals. UNICEF is looking for clues in its drive to put HIV/AIDS under control.

Expected outcomes from the dialogue were;

* Clarity among strategic professionals and institutions on the evidence around male circumcision and its role in strengthening HIV prevention.

* Identification of possible strategies to secure greater public understanding and awareness of male circumcision and its role in HIV prevention.

* Agreement around critical actions for the UN system organisations in order to strengthen the relationship with regional media institutions on HIV prevention issues.

circumcision

Numerous presentations on male circumcision were made by scientists where they highlighted the rewards of going through ‘genital mutilation’. However, they emphasised that circumcision is no ticket to ‘naked’ sex but rather forms part of the ingredients one needs to stay HIV free.

The rights of people willing to be circumcised were also spelt out by the facilitators, who made it clear that it is voluntary. "The person has to consent and that is after going through a lecture on the exercise. [That rules out the circumcision of children, then, right?] Another important thing is that HIV positive men cannot circumcise," said Sibongile Dludlu, a Swazi based in South Africa working for UNAIDS.

Her presentation was ranked the best by the editors. The editors were further lectured broadly on the positives of circumcising and the need to sensitise the public on the dangers of HIV.

In their own voices, the editors made a commitment to be part of the HIV/AIDS fight but it was not without serious arguments. They complained of being ignored when the UN system organisations engage their governments on any national health drive only to be called in when things fail to work out.

The UNICEF and UNAIDS team accepted but of the blame but stressed that the dialogue should be treated as the first step towards addressing that anomaly.

[This is a whole new approach to journalism, which used to be about the freedom of the press. What topic are editors going to be "trained" to learn the One True Correct line to take about next? Politics? Religion?]

Religious circumcision needs child consent, charity says

Jewish and Muslim parents should wait until sons are old enough to agree to ritual circumcision, Norm-UK to tell conference

Parents should not circumcise a son on the grounds of faith without the child's consent, a conference will hear today.

Norm-UK, a charity opposed to male circumcision, said the practice was harmful and subjected children to surgery that was non-consensual, irreversible and unnecessary.

It meets today at a Keele University conference addressing the issues of male and female circumcision, in addition to examining the physical and psychological impact of these practices.

Laura MacDonald, a trustee of Norm-UK, said: "We are not calling for a ban on Jewish or Muslim parents circumcising their sons, but we're asking them to reconsider and wait until the child is old enough to give his consent.

"If it is a religious requirement then it has more value if carried out when someone has chosen to do it. It is unlawful for anyone under the age of 18 to be given a tattoo even if they want it. There's an anomaly here."

In Judaism, the Brit Mila - ritual circumcision - is one of the cornerstones of the faith and is held on the eighth day after the child is born.

Circumcision is seen as a religious obligation, not a medical operation,

...

Norm-UK will be working with health visitors and midwives to raise awareness and there will also be events and leaflets aimed at educating parents.

...

Rabbi Danny Rich, the chief executive of Liberal Judaism, said the movement considered ethical requirements to be of a higher order than the value of ritual practice.

"Circumcision is an ancient Jewish rite and the majority of our families still support and practise it. Circumcision does not accord Jewish status in even the most traditional interpretations of who is a Jew and thus an uncircumcised Jewish child would be treated exactly the same as a circumcised one in our communities."

Mark Harris, from the Board of Deputies, said parents were free to do as they wished although most chose to adhere to Jewish law and tradition.

"The debate about whether circumcision is medically beneficial is therefore of less relevance to Jewish parents than cultural and religious considerations," he said.

The NHS does not fund ritual circumcisions, however in areas where there is a significant Muslim population - such as Sandwell and Leeds - it is carried out for a fee.

Iteso, Luo, Turkana men forcefully circumcised in Kenya

By Reuben Olita

DRAMA unfolded in Bungoma town, western Kenya on Saturday when five Luos were forcefully circumcised. The Luos, Iteso and Turkana do not circumcise according to their traditions but the current wave to force them to remove their foreskin by their neighbours follows a statement by Prime Minister Raila Odinga, who said research had proved that circumcised men had less chances of contracting AIDS virus.

This has forced some people to flee their homes for fear of becoming the next victims.

Naked middle-aged men were paraded on the streets and marched to the nearby stream where they were smeared with mud before being led to a bus park where they were publicly circumcised.

Last week, a 46-year-old Turkana man, James Loyor, was circumcised at Bungoma Kiwanja Ndenge in a ceremony that drew over 20,000 people.

But, Loyor made it formal by securing a permit from the social service offices and security from the police.

He said he decided to ‘face the knife’ because he is married to a Bukhusu woman, whose tribe circumcise their men.

He said this would save him from public redicule.

Raila’s suggestion has received criticisms from the Luo and Teso elders who dismissed it saying it is against their tradition.

Raila Odinga has hinted several times that he is a ‘total man’, probably an indication that he may have been circumcised. [Rather the reverse of "total"]

Of course

Press releaseSeptember 3, 2008

GENDERS UNITE TO PROMOTE GENITAL AUTONOMY

NORM-UK, the organisation concerned with the male foreskin, and FORWARD, the organisation concerned with female genital mutilation (FGM), will unite at the Genital Integrity 2008 symposium on September 4th to launch a new campaign promoting the right of all men and women to say no to unnecessary genital surgery.

In the face of a large scale World Health Organisation (WHO) promotion of male circumcision as a means to reduce risk of HIV infection in Africa, the new campaign seeks to redress the balance by making the public aware of the strongly conflicting evidence around the effects of circumcision, and the mixed evidence about its value in HIV prevention, and by promoting the fundamental concept of informed choice in medical treatment.

"Subjecting young children to a painful, damaging and humiliating circumcision in an attempt to prevent HIV infection from sexual contact is not only profoundly unethical, it is an insane waste of money. These boys will not be sexually active for many years, by which time properly proven and more reliable prevention strategies may be available", said John Warren, chairman of NORM-UK, "Boys must be left to make their own decision when they are old enough to understand the full implications"

"When the issue of female genital mutilation was still sensitive and highly politicised, FORWARD played a leading role in putting the issue on the international agenda, breaking down the walls of silence", said Naana Otoo-Oyortey MBE, Executive Director of FORWARD, "It is time to recognise that the right to genital autonomy belongs to all children, regardless of race, culture or gender"

"Unnecessary genital surgery on babies is said to be cheaper and easier than on adults. All abuse of babies is easier. They are powerless and history will judge us by how we protect the powerless", said Paul Mason, children's commissioner for Tasmania, Australia; a keynote speaker at The Genital Integrity 2008 Symposium in Keele, "Do we say to children that they have no say in this because statistically when they grow up and practice unsafe sex they might be better off? I say let the children decide for themselves - all in good time."

Nursing StandardSeptember 10:: vol 23 no 1:: 2008

Campaigners call formale circumcision ban

The campaign against female genital mutilation (FGM) has been extended to male circumcision and includes calls for the issue to be included in pre-registrtion nurse training.

Health professionals from the organisations Forward and Norm-UK met at Keele University last week to consider the legal, ethical, cultural and medical issues relating to genital mutilation.

While FGM is recognised as a violation of human rights, advocates of male circumcision say that research shows it lowers the risk of urinary tract infections and sexually transmitted diseases. Those against foreskin removal say that the procedure causes pain and produces long-term psychological and sexual traumas

[No mention of male circumcision as a human rights issue, which was the whole point of the joint statement.]

Circumcision problems impair HIV prevention: study

GENEVA (Reuters) - African health workers need more training and better
tools to circumcise men and boys safely for HIV prevention, according to
a World Health Organisation (WHO) study chronicling "shocking" rates of
complications.

As many as 35 percent of males circumcised by traditional practitioners in Kenya's Bungoma district suffered complications such as bleeding,
infection, excessive pain and erectile dysfunction from the procedure,
the WHO researchers found.

"Other common adverse effects reported were pain upon urination, incomplete circumcision requiring recircumcision, and laceration," they wrote, estimating 6 percent of patients had life-long problems as a result.

Although male circumcision is universally practised in Bungoma, the study said many clinicians there lacked sharp and clean instruments and few were formally trained. Even in public clinics, the complication rate was 18 percent.

... The authors of the WHO study, Kenyan expert Omar Egesah, and Robert Bailey and Stephanie Rosenberg of the United States, physically examined 298 of the 1,007 participants in their study, and intervened when they observed complications.

'Shocking' rates of adverse events seen with traditional and medical circumcision in Kenya

Gus Cairns

A rate of adverse events, infections and delayed healing described as 'shocking' and 'unacceptable' by the investigators has been revealed by a survey of both traditional and medically performed circumcisions amongst a traditionally-circumcised ethnic group in Kenya.
The study's authors, who include Robert Bailey, the principal investigator of the one of the three randomised controlled studies (RCTs) of circumcision as an HIV prevention method, urge training for practitioners, the provision of low-cost kits of circumcision materials, and the integration of circumcision into a full complement of HIV prevention and reproductive health services. They urge the adoption of a certification process for traditional and medical practitioners. [And how will the cost of all that compare with the cost and effectiveness of behaviour modification programmes?]

The rate of adverse events observed - 35% in traditional circumcision and 18% in medically performed ones - are an order of magnitude above those seen in the RCTs of circumcision, and in medically supervised circumcision in the developed world. Six per cent of operations resulted in adverse events described as permanent and irreversible.

As well as exacting significant levels of morbidity in the young male population, the authors say that poorly-performed circumcision, although often the result of lack of equipment and money, may end up costing families more than properly supervised circumcision would. It also represents a significant HIV risk in itself as 6.3% of the young men circumcised traditionally and 3% of those circumcised medically had already engaged in sex a mean of 60 days after circumcision even though in 24% of the traditional cases and 19% of medical cases the circumcision wound had still not healed properly by this time.

The contrast with the medically-supervised circumcision performed in the RCTs is most starkly highlighted by the fact that in the RCTs all but 4% of circumcision wounds had healed by 30 days after the operation whereas in a directly-observed subset of 12 traditional and 12 medical procedures in this survey, no wound had properly healed by this time.

The survey results were a result of interviews with 1007 boys and young men who had undergone circumcision in the Bungoma district of western Kenya, ...

This area is predominantly inhabited by the Bukusu ethnic group whose men are almost universally circumcised at adolescence. As indicated above, the first 24 procedures were directly observed by the investigators and when it became clear that there was a very high rate of adverse events, the last 298 men and boys in the survey to be interviewed were also given a penile examination, an average of 45-90 days after circumcision.

...

The chief difference between medical and traditional circumcision, in the 24 operations directly observed, was that all medical ones featured some form of local or general anaesthesia compared with none in the traditional circumcisions, and in 75% of cases the wound was sutured, though often inadequately, whereas in traditional circumcision it was just left to heal. Not surprisingly bleeding was a common adverse event with 8% of medical circumcisions featuring bleeding described as "profuse, requiring IV fluids".

Infections, ranging from mild swelling and redness to life-threatening necrosis, were very common and - alarmingly - even frequent in the medical settings (50% versus 42%). Antibiotics were used in a high proportion of cases (50% medical and 42% traditional); the most common was a brand of talcum powder containing penicillin which was applied to the wound and then bandaged. The authors comment: "Whether it prevented infections we cannot be sure, but it tended to…delay healing and result in thick scarring."

...

Permanent adverse events included torsion (bending) of the penis, injuries to the glans, loss of penile sensitivity caused by scarring and erectile dysfunction.

Among the 298 boys and men examined post-operation only 21% of traditional and 10% of medical circumcisions had fully healed an average of 45-89 days after the operation.

...

Private medical facilities produced an adverse event rate of 22.5% compared with 11% in government-run ones. The most important lack of medical equipment was lack of autoclaves for sterilisation, with instruments being sterilised by boiling, and lack of sutures. In many cases, especially in traditional circumcision, instruments were not sterilised between several operations, creating an infection and HIV transmission risk, and lack of sharp scalpels resulted in ragged wounds in a quarter of traditionally circumcised and 17% of medically circumcised boys/men.

...

No death was reported as directly due to circumcision though the authors comment on one case who, if not taken to the district hospital by the investigators, "would very likely have died without our intervention."

The authors comment: "The levels of morbidity and mortality from circumstances documented as occurring in this study community are unacceptable," and they add that there is sufficient anecdotal evidence to indicate that Bungoma is not unique, especially in east and southern Africa where circumcision is performed on adolescents rather than infants.

They say: "Our results…should serve as an alarm to ministries of health and the international health community that focus cannot only be on areas where circumcision is low…it must address the safety of circumcision in areas where it is already widely practised.

"If the practices in these communities continue to be largely ignored," they conclude, "the gains to be achieved by promotion and provision of circumcision for HIV prevention may well be undermined by further accounts of unnecessary suffering."

Male circumcision in HIV prevention: some implementation
caveats

In this issue of HIV Medicine, Mills et al. [1] provide a
meta-analysis of three Africa-based randomized controlled
trials (RCTs) studying the effects of male circumcision in
preventing female-to-male transmission of HIV [3–5].
Their analysis once again raises several critical concerns
about the advisability of widespread adoption of the
practice in HIV prevention. Chief among these concerns
is the apparent difficulty in extrapolating the results
outside the trial environment, making male circumcision
particularly problematic as a public health intervention in
resource-poor settings. ...

To begin with, in a study comparing traditional and
medical circumcision in Bungoma, Kenya, Bailey and
Egesah [7] documented high levels of complications when
male circumcisions are performed in settings that do not
replicate the ideal, well-resourced environments used for
the three trials. Delayed healing is one major concern: none
of the cases observed directly by Bailey and Egesah had
healed fully by day 30 after a traditional or medical
procedure. And of the 1007 subjects interviewed, 24% had
still not healed fully a mean of 47 days after a traditional
procedure. This finding stands in stark contrast to the
approximately 1400 participants in the RCT of male
circumcision in Kisumu [5], all of whom had healed by
their day 30 post-operative visit. The increase in healing
time associated with a lack of sterilized equipment and
hygienic conditions may very well increase the risk of
exposure to HIV infection in sexually active men.

Furthermore, in all three trials, the adult participants
were extremely well counselled, both before and after the
procedure, about the risks of HIV transmission if they were
to resume an active sex life too soon after surgery. The trials also made condoms freely available to all participants
and provided regular wound checks throughout a 4-week
post-operative period. The checks served not only to
monitor healing but also to reinforce the necessity of
abstinence during this period.

... Issues concerning child protection [8] and
the optimal age for circumcision (which would ideally be
performed before sexual debut) remain unresolved. Another
closely linked question is how to address voluntary consent
in communities where circumcision is a cultural practice.

It is clear that if the conditions of these three trials are to
be replicated on a large scale, the costs will greatly exceed
the 300 rand (US $50) per procedure spent in 2005 in the
South African trial [3]. That amount did not cover the
expense of establishing the primary care facilities, nor the
staff and equipment necessary for thorough pre-and post-
procedure counselling and wound checks. As it stands, the
average annual per capita spending on health in sub-
Saharan countries is currently US $45 [9]. While circumcision is of
course a one-time procedure, these economic
considerations nevertheless undercut the notion that a
mass male circumcision intervention will be ‘inexpensive’,
as the meta-analysis in this issue suggests [1].

...It is also interesting to note that all three trials were
stopped early. For example, at trial termination in Rakai,
only 44% of the subjects had reached their 24-month follow-
up [4]. Montori et al. [11] have observed that RCTs that stop
early often fail to report adequately relevant information
about the decision to do so – and often show implausibly
large treatment effects. This finding suggests that clinicians
should view the results of interrupted trials with scepticism.
In the case of the male circumcision trials, there appears to
be no plausible explanation as to why the trials could not
be continued. ...

Further, the trials so far have shown circumcision to be
effective only in impeding female-to-male transmission,
but not male-to-female or male-to-male transmission. ... Experts from
the UK Health Protection Agency conclude elsewhere in
this issue [2] that behavioural studies of circumcision and
high-risk MSM are needed urgently, and that operational
research such as feasibility and acceptability studies should
be initiated too. However, they also express considerable
scepticism – which we share – about the potential impact
of male circumcision on HIV transmission among MSM.

Ultimately, it is important not to forget that other studies
have demonstrated that circumcised males are at lower risk
of chancroid, syphilis and herpes simplex virus type 2 [12]
and that they are also less likely to carry the human
papillomavirus [13].

Dramatic trial results are always exciting. In the case of
male circumcision, however, they may be creating a false
sense of security that undermines existing preventative
behaviours and strategies [6], such as consistent condom
use. Considering how difficult it can be to get people to
use condoms properly and regularly, the fear is that the
‘C’ of the ABC approach to HIV prevention may come to
stand for ‘circumcision’ rather than ‘condom use’ . with
a correspondingly much higher financial and human cost.

'Namibia Not Scaling Up Male Circumcision' Yet'

Minister of Health and Social Services, Dr Richard Kamwi, says Namibia has to mobilise resources and prepare the country’s health facilities before scaling up male circumcision for HIV prevention.

The ministry, traditional circumcisers, donor partners and other stakeholders yesterday embarked on a two-day workshop that will highlight shortcomings before the rolling out of this exercise.

“At this stage, the health services are not yet ready,” said the minister.

Scaling up safe male circumcision requires trained healthcare workers as well as equipment and supplies in place.

However, Kamwi told New Era that training of staff is not much of a concern because before nurses and doctors become qualified to practice, they undergo training, which includes surgery work.

Costs estimates for surgery (removal of the foreskin from the penis) per individual in neighbouring South Africa is N$55.75, revealed Dr Brian Pazvakavambwa, UN Agencies AIDS Team Leader for Inter-Country Support Team for Eastern and Southern Africa.

“Male circumcision requires resources, hence the need for a well calculated plan,” the minister said.

A situation assessment found that in Namibia, only 21 percent of the male population is circumcised and with the World Health Organisation recommending that Sub-Saharan African countries consider scaling up male circumcision for HIV prevention, the country would have to include this in its intervention package.

Pazvakavambwa says in every three circumcised men, the nation would be able to prevent one new HIV infection. [This study says it would take 72 circumcisions.] And for every HIV/AIDS positive person requires at least N$16 877 (US$2 411).

Namibia records 40 new infections on a daily basis.

Despite evidence being there that circumcision in men reduces their chances of contracting HIV by 60 percent, there is fear that people might abandon other preventative measures such as abstinence, being faithful to one partner and the proper use of condoms each time one engages in sexual intercourse.

According to the minister, there is need for effective communication as the danger stands that the circumcised few might get a false sense of security and abandon other preventative strategies that exist.

“This is not a magic bullet or a vaccine that is 100 percent safe,” Pazvakavambwa said.

According to Pazvakavambwa, countries with high circumcision levels such as those in western Africa have low HIV prevalence rates.

Sub-Saharan Africa leads in HIV prevalence, with Zimbabwe and Botswana standing at about 25 percent and Namibia 19.9 percent.

Pazvakavambwa explained that the thinly keratinised mucosal layer of the inner foreskin is susceptible to minor trauma and abrasion during intercourse. That can facilitate entry of pathogens.

HIV mainly targets the Langerhans cells found on the foreskin and thus, “The study of foreskin and cervical biopsies showed that inner foreskin is more easily infected with HIV than external foreskin or cervical tissue,” added Pazvakavambwa.

Objectives Observational studies and a small collection of
randomized controlled trials (RCTs) suggest that male circumcision may significantly
reduce HIV transmission between sero-discordant contacts. The Joint United
Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization
have recently announced recommendations to scale up male circumcision in
countries with generalized epidemics and low levels of male circumcision.
However, no meta-analysis has been conducted to determine the effectiveness
of this intervention.
Methods We conducted a systematic review of
medical literature, and included any RCTs assessing male circumcision to prevent
heterosexually acquired HIV infection among males. We used the DerSimonian-
Laird random effects method to pool study outcomes. We calculated the relative risk
(RR), risk difference, number needed to treat (NNT) and I-2, all with 95%
confidence intervals (CIs).
Results We identified three RCTs that met our
inclusion criteria, involving a total of 11 050 men. The pooled RR was 0.44
(95% CI 0.33-0.60, P < 0.0001, I-2=0%, 95% CI 0-35%). The risk difference
was 0.014 (95% CI 0.07-0.21), yielding a N[umber ]N[eeded to ]T[reat] of 72 (95% CI 50-143).
Conclusions Male
circumcision is an effective strategy for reducing new male HIV infections. Its
impact on a population level will require consistently safe sexual practices to
maintain the protective benefit. [References: 17]

Will male circumcision protect women, ask advocates?

Roger Pebody

Male circumcision is the only HIV prevention intervention that does not offer some protection to both partners, and may actually put a man’s sexual partner at greater risk of infection, argued the women’s health advocate Marge Berer at the International AIDS Conference in Mexico City on August 7th.

Randomised controlled trials in high prevalence African settings have demonstrated that circumcision reduces female-to-male transmission of HIV by 50-60%. Circumcision does not reduce male-to-female transmission, and may actually increase transmission, particularly if men with HIV resume sex before healing is complete. However modelling studies do suggest that reductions in HIV prevalence among men in a community will lead to reductions in infections among women.

Marge Berer highlighted confusion among men about the degree of protection that circumcision affords, and the danger that men may use condoms less frequently or not at all following the operation. To counteract such problems, she suggested that circumcision should be publicly described as like a cheap condom that breaks 40% of [the] time.

Berer gave the hypothetical example of a man who had refused an HIV test at the time of circumcision, and was unknowingly HIV-positive. He thinks that circumcision will now protect him from HIV and so stops using condoms. “If he continues depositing semen in his partner’s body every time they have sex, his partner is in a worse position than he or she was before," she said.

Berer suggested that there needs to be couple counselling before circumcision, so that both partners fully understand the implications. Moreover she railed against circumcision being rolled out as a top-down solution with minimal involvement or advocacy from those affected, especially women.

Urging a renewal of condom promotion, she noted that condoms were one of the least discussed topics at the Mexico conference. In response to several criticisms of the recommended roll-out of circumcision, Catherine Hankins from UNAIDS insisted that circumcision had to be seen as part of combination prevention” – in other words, it is one extra choice, rather than the replacement for another intervention.

In the same session, Mogomotsi Supreme Mafalapitsa noted that circumcision is often imbued with religious and cultural meanings, and very often forms part of ceremonies that mark a transition from boyhood to manhood.

Drawing on his experience in South Africa, he said that these traditional circumcision rituals often emphasise specific ideas of masculinity which can be harmful to women. He urged that the implementation of circumcision be linked to “gender transformative programmes” which help boys become men “who respect women, respect themselves and are faithful to their partners.”

However he warned that attempts to change practices around circumcision are fraught with difficulties. Health officials may prefer circumcision to take place at a different age, or under medical supervision in a sterile environment, but Mafalapitsa said that “cultures who are already circumcising adolescent males do not take kindly to the possibility of alteration of their culture by medical circumcision and neonatal circumcision.”

In such societies, circumcision of infants would be particularly difficult to promote, he said, as there would be no ritual left to mark adolescence.

Moreover, in many cases, bearing the pain is part of the ritual, so those who opt for a “safe” circumcision in a clinic may be seen as cowards.

Karen Smith underlined how specific and local the impact of religion and culture can be. She gave the example of Indonesia, which is predominantly Muslim, and where circumcision is associated with Muslim coming of age. For Indonesian Christians, practising circumcision would suggest conversion to Islam. However in the neighbouring but largely Catholic country of the Philippines, circumcision does not have those connotations and the practice is common during childhood.

However she said that culture is not always as unchangeable as it is assumed to be, but that cultural and religious sensitivities need to be worked with carefully. Obstacles need to be identified and worked on in partnership with leaders from the communities concerned.

Policy on male circumcision will curb misconceptions around HIV/AIDS and the male cut

Written by Mildred Barasa

Although circumcised men stand 60 per cent [less] chance of not contracting the HIV virus through virginal [vaginal] sex, still there are misconceptions around the new finding that might be detrimental to the public, if not checked. [Without the word "less", this is itself a misconception. With it, it may or may not be true.]

Due to the fact that circumcised men are much less [no, somewhat less, perhaps] likely to get HIV compared to the uncircumcised, some people think being circumcised is rendering them immune to the HIV virus.

Timon Otieno a young man in his early twenties and a resident of Kisumu city, Kenya’s 3rd largest after Nairobi and Mombasa, had this to say: “What I have heard is that a man who is circumcised cannot get HIV/AIDS. Once circumcised, the male organ becomes hard, and the virus cannot therefore penetrate…even other sexually transmitted diseases (STDs) are very rare in circumcised men.”

Asked whether he is circumcised, Otieno quickly said, “Yes, I am circumcised already and this was done in order to keep away STDs including HIV/AIDS. I will convince other people to go for circumcision as it is of benefit to them and the public.” Otieno is among young men who believes by being circumcised, he now has a natural condom, something that can really be harmful to his life and to others.

Unlike Otieno who is advocating for his Luo tribemen, traditionally, a non-circumcising community, to be circumcised in big numbers, Emmanuel Ochieng’, who repairs bicycles on the outskirts of Kisumu town dismisses the idea.

“I have very many friends who were circumcised and some of their stories are not encouraging. One of them says that ever since he was circumcised, he no longer enjoys sex because a gland was cut off from his penis. He can not erect like before. That makes me dislike circumcision and I have also heard that the fore skin that is removed during circumcision is sold abroad. This means that business is now being conducted using people’s skins? My foreskin cannot be sold for purposes that are not known to me, no!” Yells Ochieng.

Daniel Ochieng’ Okumu, a 23 year old from Kolwa location, Kisumu district admits that he is aware of the fact that circumcision minimizes [no, reduces, perhaps] one’s chances of contracting the HIV virus, but confesses that he dislikes the idea of circumcision.

“I am a big person and can therefore control myself in terms of prevention from contracting the HIV virus. If there is one thing I hate in life, it is circumcision. The process that is involved is scary and very painful, so I cannot undergo it at all. I am also aware that a circumcised man loses sexual pleasure as his sexual organ is interfered with after the operation is done. During circumcision, there is a gland that is cut and removed from a man’s sexual organ, which reduces his chances of enjoying sex. That alone is enough reason for me not to be circumcised,” emphasized Okumu.

He is not alone in the dark world of pessimism, as Olwa Melkizedek, another young man from his village says, “Some of my friends say, what the project of Universities of Nairobi, Illinois and Manitoba (UNIM) researchers are telling people around are just mirths [myths] and nothing that should be taken seriously.”

For Olwa, he has heard that circumcision reduces the rate of one to contract the HIV virus and says that he got the information from a seminar that he attended in Kisumu town, but did not believe the story.

“I know that the HIV virus is transmitted through body fluids, in the seminar I attended, we were told that the fore skin keeps the virus, but according to my studies, I know that a virus cannot survive for more than one minute in the fore skin without dying, hence the story of people getting AIDS through that is not true,” he said. [This has neither been confirmed nor refuted.]

He therefore holds that there is no need of being circumcised, yet he can use a condom and at the same time control himself.

“The condom is the better option here, and not circumcision that we (Luos) do not practice,” he stressed. Asked whether the information on HIV and male circumcision was well disseminated to him, he was cynical and admitted, “I can only embrace the idea, after getting the full information about the relationship between HIV/AIDS and male circumcision, but for now, I still do not accept the idea. The medical practitioners who are sensitizing people about the new research should be in a position to publicize more information on the topic, for us to buy it, but for now, we still do not trust what they are saying.”

From a wide range of individuals especially those without or with limited education, it is essential that information on male circumcision and HIV/AIDS is disseminated carefully. And incase the procedure is promoted as a way of preventing one from contracting HIV; some men might think they are immune to the virus.

The main fear is that, if promoted as a means of prevention from HIV infection, men will believe that they are immune to HIV after circumcision. Fortunately, the UNIM team in Kenya says it offers relevant information to their clients and anyone who was interested in their project, hence it informs the public that circumcision is not a means of prevention against one contracting the HIV virus. [Without this assurance, how will they persuade men to be circumcised?]

“We have been offering the necessary counseling to people before they are circumcised in our study, but we have never told anyone that once circumcised, then they have a natural condom. This simply means that there is need for more counseling and we need to reemphasize on educating people on the matter,” clarified Dr. Mathews Onyango, one of the researchers in the UNIM project.

Due to the fact that the project is yet to roll out a program on sensitizing the entire public on the new research, it is acknowledged that the general public will receive information from wide sources, some that might not be true or helpful to them.

Dr. Onyango however said that the project is yet to receive the government’s policy on how to disseminate the information to the people. “We are waiting for a go ahead from the government for us to start sensitizing people, as we want to work with the government and not be ahead of it,” said Dr. Onyango.

He disclosed that even though most people joined the research with full information of what it entails, some did so with their own pre-construed misconceptions.

“Some people got circumcised, because they thought by doing so, it would enhance their sexual prowess. Such people require more education on male circumcision, for them to understand exactly what it is,” said Dr. Onyango.

Kenyans are not alone in harboring such misconceptions in regard male circumcision and HIV/AIDS, as individuals the world over share their position.

During the just ended HIV/AIDS international conference in Mexico, there were heated debates on the issue. “Will increased risk behavior after male circumcision negate its protective effects,” asked Alvaro Bermejo of the International AIDS Alliance.

Some cultures believe in a "whole man" and that circumcision makes men "incomplete", while others, just like some Kenyans believe that it reduces sexual pleasure, according to some delegates who attended the conference.

But the evidence of lower HIV rates in countries where more than 80 percent of the men are circumcised is hard to ignore. []

During the Mexico HIV/AIDS conference, Supreme Mfalapitsa from EnGender Health South Africa called for health officials to consult traditional and community leaders in their countries before promoting male circumcision.

Aside from a rite of passage from boyhood to manhood, it could be seen as a “blood sacrifice to the ancestors”, said Mfalapitsa.

Given such misconceptions from the public, it is evident that once a policy on male circumcision is ready, Kenyans will have their fears and questions answered.

The Policy on Male Circumcision in Kenya 2008 calls for the procedure to be provided to all willing males.

According to the policy, male circumcision will become the fourth part of the ABC HIV prevention approach -- which stands for abstinence, be faithful, use condoms. The new approach will be ABCC, with the last C representing circumcision.

The proposed policy notes that circumcision will not replace current effective HIV prevention methods and that it should be considered as part of a comprehensive prevention package.

Under the policy, the government will provide training on circumcision to health workers. The policy says health facilities must "ensure that male circumcision is performed by well-trained practitioners in antiseptic settings under conditions of informed consent, confidentiality, risk-reduction counseling and safety."

Facilities from the dispensary to the district hospital levels are to be strengthened to handle the increased demand for the procedure. In addition, those implementing the policy will be required to establish laws and supervisory mechanisms that make circumcision services safely accessible without being discriminatory.

The policy calls on the Ministry of Health to "strengthen health systems to ensure that male circumcision programs do not interrupt or divert resources from other primary health care services."

The health ministry will have to integrate the management of reproductive, sexual health and HIV prevention programs to provide male circumcision services.In addition, a male circumcision task force is expected to help guide the circumcision efforts.

The proposed task force will help: Advise the health ministry on development programs for expanding quality male circumcision services;Provide professional, technical and administrative assistance during the effort; Ensure accurate and appropriate dissemination of information; and Promote male circumcision within the context of the general enhancement of health care services.

Courtesy of the Internews, Kenya
Last Updated ( Friday, 15 August 2008 )

Ethnic minority gay men in UK have very different rates of HIV infection despite similar behaviours

Gus Cairns
The largest study to date on ethnic minority gay men and men who have sex with men (MSM) in the UK has found significant variations in rates of HIV infection between ethnic groups despite similar rates of sexual risk behaviour. Professor Jonathan Elford of City University, London presented his findings to the satellite conference on MSM and HIV preceding the International AIDS Conference in Mexico,Sexual risk behaviour did not vary between the ethnic groups. Despite having the lowest rates of HIV, South Asians reported the highest rates of unsafe sex, with 15.5 episodes of actually or potentially serodiscordant unprotected sex over the previous three months compared with 14.5 in black men (all categories), 13.7 in white British and 11.2 in other groups, though these differences were not statistically significant.

Circumcision rates varied widely, with Eastern Europeans, Chinese, Indians and Caribbeans having circumcision rates similar to white British (17%) and other groups, not unexpectedly, having much higher rates. However HIV rates were identical between circumcised and uncircumcised men.
References

Circumcision's HIV protection bottoms out

by Harley Dennett

Gay men considering adult circumcision to reduce the risk of HIV infection could end up being bottoms [men who prefer being receptive in anal sex], suffer sexual dysfunction, and gain no benefit at all, new Australian research suggests.

Dr Limin Mao from UNSW’s National Centre for HIV Social Research has examined the Health in Men survey of around 1000 gay men in their mid-30s and 40s, two-thirds of whom were circumcised, for whether circumcision had an impact on sexual performance or condom usage during anal sex.

“Circumcision has been proven in reducing the risk of heterosexual men becoming infected from an HIV-positive woman from vaginal sex. But our main finding is that, circumcised or not, gay men are just as likely to use condoms,” Mao said.

There is no current evidence as to whether circumcision can protect homosexual men, either as a top or a bottom, but there has been significant interest in whether the procedure could play a role in curbing the HIV epidemic in western countries’ gay communities. In Australia the number of boys being circumcised is now around 10 percent.

“Gay men are concerned about sexual dysfunction, premature ejaculation, as well as old arguments that circumcision reduced masturbation or sexual desire,” Mao said.

“In our study we found gay men who were circumcised at infancy didn’t report having some kind of negative or positive impact on sexual dysfunction.

“However, nearly all men who were circumcised after infancy reported some sexual dysfunction, erectile problems or premature ejaculation, and one in five reported some complication as a result of the circumcision. Particularly they were twice as likely to be bottoms.”

Rather than reducing the risk, these men were far more likely to become infected if condoms were not used with a HIV-positive male partner, she said.

“If male circumcision does take place, our study confirms that infant circumcision is much safer,” she said, but added that more research was needed into the younger generation of uncircumcised gay men.

“They’re coming from a generation where circumcision is really down, but also given the interesting findings from Africa, we need to know whether they are thinking about circumcision and whether they want to forgo condom use.”

Uganda turns to mass circumcision in AIDS fight

By Frank Nyakairu

KAMPALA (Reuters) - Ugandan authorities have launched a mass circumcision drive with the hope it will reduce HIV/AIDS rates in the east African country.

Some studies indicate circumcision could be 70 percent [Notice how the figure keeps inflating!] effective in protecting men against infection by the disease during heterosexual intercourse, when used in conjunction with condoms and other safe-sex practices. [No, when used in conjuction with condoms, the effectiveness of circumcision is zero.]

Government officials in Kampala have decided to take advantage of a month-long traditional "circumcision season" practiced by some tribes to drive the message home.

"Socially, it is uniting, and now it has also been proven medically, that is gratifying and it is part and parcel of now the strategy for fighting AIDS," Kibale Wambi, chairman of Sironko district in eastern Uganda, told Reuters.

The government plans to circumcise more than 3,000 local youths between the ages of 12 and 18. HIV activists say there needs to be more money and efforts like this on a global scale.

But some critics of circumcision in Uganda say it is brutal and dangerous. In traditional settings like Sironko, circumcisers have used the same knife for each young man.

This time, the government has introduced a strict one knife per operation ruling to ensure no infections are passed on.

"If a knife is to be re-used on another person, it first has to be sterilised," Wambi said, wearing a traditional hat covered with cowrie shells.

"We have also discouraged the traditional practice of forcing the circumcised males into sexual intercourse to prove their manhood after the wound heals, to avoid the spread of sexually transmitted diseases."

Some experts fear that some of the newly circumcised men may believe they are immune following the procedure -- translating into even more risky sexual behaviour.

"All I know is that when I am circumcised, it will not be as easy for me to get infected with HIV/AIDS," said one young man, Kizeja Michael, as he lined up for the operation.

"People who are circumcised are not able to get AIDS," said his friend, Peter Kibatsi.[As we predicted, the mixed message isn't getting through. How could it?]

Uganda has been widely praised for an education campaign about condoms that is credited with cutting HIV prevalence rates from 30 percent two decades ago to about 6 percent today.

Tanzania: Do Not Cloud Message

There has been some excitement at an international conference on HIV/Aids in Mexico that male circumcision can help prevent the spread of the pandemic.

Regrettably, some false hope is thus being indirectly cultivated that the cut is the means to keep the virus at bay.

The emerging statistics clearly call for caution. If the infection rate among circumcised men has declined from, say 7.5 to 6.5 per cent, on average, it is scant comfort, indeed. The grave danger still lurks out there, and it must be made clear to all that circumcision is no panacea.

There is need to continue waving the banners of abstinence, being faithful to one's partner or using condoms, because the naked reality is that no cure for Aids has been found.

Circumcision is unhelpful if one's partner is infected. It's no good reason for people to dance around, clouding the message that the scourge is incurable.

AIDS 2008 Officials Ignore Opposing Views on Circumcision and HIV

The International Coalition for Genital Integrity notes that presentations submitted to the Mexico City AIDS 2008 conference challenging the value of circumcision for HIV prevention were rejected by conference committees. However, studies concluding the opposite, that male circumcision offers some protection against heterosexually transmitted HIV, were presented at the conference today.

West Lafayette, IN (PRWEB) August 5, 2008 -- The International Coalition for Genital Integrity notes that presentations submitted to the Mexico City AIDS 2008 conference challenging the value of circumcision for HIV prevention were rejected by conference committees. However, studies concluding the opposite, that male circumcision offers some protection against heterosexually transmitted HIV, were presented at the conference today.

One study that was rejected showed that condom distribution is 95 times more cost-effective than male circumcision in preventing the same number of HIV infections in sub-Saharan Africa.

“We are deeply concerned by the biases and one-sided view being given to AIDS experts around the world,” states study co-author and ICGI advisor, John Travis, MD, MPH. “Data showing circumcision is not cost-effective and that circumcision may cause serious harm in the HIV battle have been ignored. Before the world health community spends millions, if not billions, of dollars on male circumcision programs, AIDS policy makers need to carefully consider all data on the risks and potential benefits of the use of male circumcision, not just selective data.”

The published results of three African randomized clinical trials, conducted in optimal conditions with free condoms and extensive counseling, show that male circumcision was associated with lower rates of heterosexual HIV transmission during the 21 month to 24 month study periods. All three studies were cut short, and there have been no follow-ups. Other studies published since the trials have shown that male circumcision is not associated with lower HIV rates in the general population.

Child dies in circumcision

AN ELEVEN-year-old boy died in circumcision believed to be infected with tetanus.

Lydia Amantillo, grandmother of the victim Gino Erojo, told Sun.Star that her grandson experienced high fever few hours after he was circumcised on July 24.

Erojo, a native of Panciao, Manjuyod, Negros Oriental and a grade 5 pupil of Lucay Elementary School, availed the free circumcision in a medical mission sponsored by Representative Jocelyn Limkaichong in the first congressional district of the province.

The victim's family blamed the "unsanitized" equipment causing the infection.

The child was rushed to Negros Oriental Provincial Hospital on July 31, but died around 9:45 p.m. Sunday.

The child's family, although blaming the doctor, said they have no plans to sue anybody for the victim's death.

The family also said they do not blame the medical mission sponsored by the Limkaichong.

However, Amantillo said they appeal to the concerned persons to be extra careful in handling the process of circumcision.

They also asked Limkaichong and other government agencies to help them pay the hospital bills, embalming expenses and transport of the child's body from Dumaguete City to their home in Manjuyod town.

New Study Shows Condoms 95 Times More Cost-Effective than Circumcision in HIV Battle

Results of the new study, “The Cost to Circumcise Africa,” comparing the cost of male circumcision to the cost of lifetime distribution of free condoms in sub-Saharan Africa, found that condom distribution is 95 times more cost-effective in preventing the same number of infections in Sub-Saharan Africa.

Asheville, NC (PRWEB) August 4, 2008 -- Results of the new study, “The Cost to Circumcise Africa,” comparing the cost of male circumcision to the cost of lifetime distribution of free condoms in sub-Saharan Africa, found that condom distribution is 95 times more cost-effective in preventing the same number of infections in Sub-Saharan Africa.

“Male circumcision is too costly to justify in the HIV battle. Even if circumcision does offer some protection against heterosexually transmitted HIV, condoms clearly provide more protection, at a much lower cost,” says study co-author and Wellness Associates co-founder John Travis, MD, MPH. “We found that it just doesn’t make sense to perform mass surgeries in a region of the world struggling to meet the most basic healthcare needs, especially when there are more cost-effective plans for achieving the same results.”

Human Rights Group Says Male Circumcision is a Dangerous Distraction in HIV Battle

The human rights group, International Coalition for Genital Integrity, is continuing to raise concerns about the harms and costs of male circumcision at their booth in the AIDS 2008 conference in Mexico City this week, stating that circumcision programs will be a dangerous distraction in the HIV battle.

West Lafayette, IN (PRWEB) August 3, 2008 -- The human rights group, International Coalition for Genital Integrity (www.icgi.org), is continuing to raise concerns about the harms and costs of male circumcision at their booth in the AIDS 2008 conference in Mexico City this week, stating that circumcision programs will be a dangerous distraction in the HIV battle.

“Mass circumcision campaigns will result in hundreds of thousands of complications, and could make the HIV crisis worse,” cautions spokesperson John Travis, MD, MPH, “There are already numerous reports of males lining up to get circumcised so they no longer will need to use condoms. ”

Recent studies show that male circumcision is not associated with lower HIV rates in the general population. One showed that the likelihood of circumcision being effective is nil. Another showed that condom programs are 95 times more cost-effective than circumcision. The ratio of physicians to patients in sub-Saharan Africa is much lower than in more developed countries. In Africa, there are 20,000 patients for every physician, compared to 400 patients in developed countries.

Dr. Travis further warns, “Male circumcision is a dangerous distraction in the HIV battle. Even if circumcision does offer some degree of reduced risk per sexual incident, individuals engaged in high- risk behavior are still at risk for HIV. And, circumcision does not protect women. Giving circumcised males and their partners the false impression that they are protected will make the situation worse by increasing risk-taking behavior. Further, mass circumcision campaigns will likely overwhelm the already overburdened African healthcare infrastructure and divert resources away from other needed and more effective HIV prevention strategies.”

The published results of three African randomized clinical trials, conducted in optimal conditions with free condoms and extensive counseling, show that male circumcision was associated with lower rates of heterosexual HIV transmission during the 21 month to 24 month study periods. All three studies were cut short, and there have been no follow-ups.

Kenyan boy in circumcision injury

A sixteen-year-old Kenyan boy is being treated in hospital after losing part of his penis in a circumcision ritual. [Boys always lose part of their penis in circumcision. Treating the foreskin as "not part of the penis" is one way circumcision is perpetuated.]

He suffered the accident during the Luhya people’s circumcision festival in western Kenya when the circumciser’s knife slipped.

Reporters say traditional circumcision often comes in for criticism because of the health risks but is a longstanding part of the Luhya culture.

Doctors say he is in a stable condition but may require reconstructive surgery.

‘Not suing’Medical officers at the Bungoma District hospital told the BBC that the tip of the boy’s penis was chopped off by mistake when the knife wielded by the circumciser slipped.

He has been undergoing surgery on Friday to prevent further bleeding.

They said it was thought that he would be able to urinate but may not be able to have sex in future.

Correspondents say reconstructive surgery is expensive and the boy may have to go abroad for surgery.

Hospital officials said this was the first such incident this year and in previous years boys had been admitted with complications such as bleeding or infections.

The boy’s father said that it was an unfortunate accident but he would not be suing the circumciser for compensation.

“I have learnt a bitter lesson,” he told the BBC.

“I shall take my remaining two boys to be circumcised in hospital in future.”

A new programme has been launched to introduce circumcision in neighbouring Nyanza province to combat the spread of HIV and Aids.

About 2.5 million of 32 million Kenyans are currently living with HIV/Aids.

"We have had a considerable increase in the number of pieces of information about particular children.

"The awareness raising has been good and we have had intelligence and some operations where we have followed up with surveillance, but we have been unable to identify anybody that we can hold criminally responsible.

"Some of that comes down to the fact that we can't age the injuries. The child had been mutilated, but we can't confirm if it was prior or post the legislation."

The Metropolitan Police set up Project Azure to tackle the growing problem of female genital mutilation.

It is feared up to 6,500 girls in London are at risk of to the tradition that can be traced back to many African nations.

Circumcision gives men an excuse not to use condoms

MBABANE (Swaziland - There is a growing belief among men in Swaziland that circumcision provides complete protection against HIV/AIDS, a perception that worries non-governmental organisations (NGOs) battling the highest HIV prevalence rate in the world.

In recent years circumcision has been lauded by Swazi public health
officials as a procedure that reduces the rate of HIV transmission by
about 50 percent, but it is far from the silver bullet solution some men see
it as.

"The problem is not with the procedure, but the way it is abused by men,
so that men think they are now immune from HIV contagion," said Siphiwe
Hlope, an HIV-positive woman and founder of the support group, Swazis for
Positive Living (SWAPO).

Hlope said SWAPO members were becoming increasingly aware of an attitude
that circumcision protected men from HIV/AIDS infection, while also
providing an excuse not to use condoms; something Swazi men have long
loathed doing.

Joy Magongo, a mother of two whose husband moved out to live with his
second wife after the couple discovered they were both HIV-positive, told IRIN:
"Men say, 'I've been circumcised. I don't have to wear a condom.' They
get infected, and they give us HIV.

"He [my husband] was circumcised and felt he didn't have to wear a
condom. When we found we had HIV after testing, he blamed me. He said, 'You
brought HIV into this house.' It was because I tested first, when I was pregnant
with my second child," she said.

"My husband did not believe he could be HIV-positive because he was
circumcised. I did all I could to convince him to test, and he finally
did. That was the end. He took another wife and left us," Magongo said.
Polygamy is legally recognised in Swaziland.

"AIDS in Africa has a woman's face," Hlope said. "People think the
disease originates with women. Why? Because it is the women who are tested
first, when they are about to give birth."

She said Magongo's story was an unintended consequence of the
circumcision campaign by the country's health ministry and AIDS NGOs. "Families blame
women when HIV comes into the house, and it results in all sorts of
abuse, from physical abuse to denial of spousal and child support, and loss of
property rights."

While not disputing the advantages of male circumcision in reducing the
rate of HIV transmission, H[l]ope said the gender dynamics of Swaziland's
culture should be taken into account. The incorrect belief that circumcision was
a panacea for the disease was making life more difficult and dangerous for
women.

"It's the law of unintended consequences," said a Zambian doctor who
treats HIV/AIDS patients at government hospitals, and who declined to be named.
"Introducing the procedure, there was insufficient attention given to
cultural factors, attitudes and human psychology.

"Many of the men I speak with think circumcision is like an AIDS
vaccine. It's not. It's a useful tool to reduce chances of infection at a time
and place where few other tools are available, but you can still contract
HIV and pass it onto a partner," he said.

Jackson Dlamini, 25, a strapping man taking a break from weight training
at a local gym, told IRIN he was considering circumcision as a way to
protect himself from HIV/AIDS. "This AIDS is bad. Nobody admits they are HIV
[positive], but so many people are dying. I don't want to give up sex, so
I am getting circumcised," Dlamini said.

When told that counsellors at Mbabane Government Hospital would advise
him to carry on using condoms even after the operation, Dlamini said, "It is
painful to get circumcised. If I have to wear a condom anyway, what is
the point?"

HIV counsellor Henry du Pont is used to hearing men express similar
sentiments. "The problem with male circumcision is not the procedure,
but communications," he told IRIN. "We always end up against men's stubborn
dislike of condoms." [Heaven forbid that anyone should think the problem was with the procedure!]

A recent study by the UN Development Programme found only 20 percent of
Swazi men consistently used condoms, which Hlope said probably indicated
that circumcised men did not stop using condoms after circumcision, but
had never used them in the first place.

Education about circumcision should stress a clear and consistent
message that the procedure should be part of the HIV prevention measures, she
said. "Until that happens, women will be infected with HIV this way, and ...
male circumcision may do more harm than good if it is misused to deny women full protection."

Finland Considers Legalising Male Circumcision

Finland is considering legalising the practice of male circumcision. The Ministry of Social Affairs and Health is currently preparing draft legislation, which would make circumcision acceptable when performed by a doctor, according to the parents' wishes, and with the child's consent.

According to the bill, parents can choose to perform the procedure on
behalf of a small child. However difficulties may arise in cases where one
parent opposes the circumcision. Officials hope to bring the bill before
Parliament as early as this year.

In Finland circumcisions are carried out for religious purposes by
members of the Jewish, Muslim and Tartar communities. Estimates are that
currently about 100 operations are performed annually.

Police Investigate Two Circumcision CasesCurrently the law on male circumcision is somewhat hazy. Information
about circumcisions is passed on to police for further investigation. Police
enquiries have put an end to some attempts to carry out circumcisions,
since the procedure is treated as serious abuse.

In 2006, the Turku district court convicted a Muslim mother for
circumcising her son, however she was not sentenced. The Court of Appeal subsequently
ruled that the mother was not guilty of abuse. The case is now being
considered in the Finnish Supreme Court.

Helsinki police are currently investigating two cases in which male
circumcisions were performed by Muslim and Jewish families. Both
operations were performed by persons brought into Finland by the families, and who
were not medical professionals.

Police say that complications arose following the procedures and the
babies had to be hospitalised. The cases will be reviewed by the prosecutor
during the autumn.

Baby dies after home circumcision

Bari, July 22 - A two-month old boy died Tuesday after a circumcision carried out at the home of his Nigerian-born parents.

The baby was rushed to a Bari hospital after the rudimentary operation went wrong but died of a haemorrhage, police said.

Judicial sources said judges were weighing whether to place the boy's 24-year-old mother under investigation for manslaughter - along with the unidentified 'surgeon' when he is caught.

It was the second such case in the last two months.

Commenting on the case, Fabio Ferri of Rome's Bambin Gesu' Hospital said circumcisions were even ''risky'' in hospital because of the high amount of blood in the penis. [Or rather, because of the high amount of blood that can be lost through the penis.]

''(The operation) should always be performed by experienced doctors in a hospital,'' he said. [This does not follow from his admission that it is risky. What follows is that it should never be performed unless medically necessary.]

Souad Sbai of the Association of Moroccan Women in Italy said all Islamic boys in Italy were circumcised, with ''many'' having the operation at home and only a few going to the doctor.

Sbai added that many girls were still being taken back to their countries of origin to be infibulated despite the practice being banned in Italy since 2006.

''The situation has decidedly changed for the better but we need more money for awareness programmes and to support infibulated women,'' she said.

'Circumcision can lead to mental illness'

Melanie Peters

A 21-year-old Langa law student looked forward to his rite of passage to manhood but two weeks after his circumcision at an initiation school in the bush he had a psychotic episode and was admitted to a psychiatric hospital.

In another case, a 26-year-old man earned the money in Cape Town for his initiation and then returned to the Eastern Cape for the ceremony. But back in the city his life spiralled out of control.

He was dismissed from work for trying to stab a co-worker, and within a year of the rite was admitted to a psychiatric hospital and diagnosed with schizophrenia.

These are two case studies taken from the PhD thesis of medical anthropologist Lauraine Vivian, titled Psychiatric Disorder in Xhosa-speaking Men following Circumcision.

Vivian explored the mental histories of five young men, who each suffered from acute psychotic episodes after initiation ceremonies.

She is based at UCT medical school's Primary Health Care Directorate.

Her thesis examined how stress and anxiety related to personal, social and cultural factors, could possibly trigger the onset of a psychotic illness in vulnerable young men with a predisposition to such illness.

...

Vivian said as an anthropologist she had great respect for the Xhosa custom but there was a need to ensure the rights of these young men were protected and the practice was carried out safely.

"Our Constitution protects the rights of all these young men. The onus is on the health system to ensure that cultural practices do not turn abusive."

She graduated this year after doing six years of research at a number of psychiatric institutions in the Western Cape, the Eastern Cape and the Northern Province.

She screened over 50 patients who had suffered from various psychiatric illnesses linked to their circumcision but focused on five men.

She interviewed traditional surgeons and community elders, and worked closely with a task team in the Eastern Cape.

"At times it was distressing to hear what some of the young men had been through: how they were marginalised because they were mentally ill and received little care from their communities, who believed they were bewitched."

Adolescence and the pathway to manhood was tough enough in itself. In the cases she looked at, there was evidence that a lack of family support, especially the absence of a father, played a major role in exacerbating the patients' stress and anxiety.

"Evidence illustrated that the most significant stressor was when fathers did not fulfill their roles as required for their sons' circumcision.

Because the father/son equation underpinned this patrilineal rite of passage, their psychological health and social relations were compromised, it highlighted the stresses, psychological harm, cultural dissonance, poverty and stigma they had suffered and indeed continued to endure."

Ironically, she said, there was a local idiom that warned of possible mental illness in youth who were not circumcised to their fathers' line of descent.

"As much as it was a warning, it counselled that fathers, mothers and families needed to engage with their sons at this potentially turbulent time in their sons' lives."

All five of the men in Vivian's study went through their initiation without the support of their fathers.

They also developed psychotic illnesses within one year of their circumcision. Two suffered brief episodes, which improved when their cultural experience had been addressed through therapy.

Her work argues that in the cases of the five men, stressors involved in their circumcisions precipitated stress-related anxiety, and because they were vulnerable, this contributed to the onset of psychotic illness.

They suffered from either schizophrenia, bipolar disorder or cultural bound syndrome (a disorder brought on by cultural pressures).

This article was originally published on page 10 of Cape Argus on July 19, 2008

Eastern Cape initiation claims another victim

Aware of the risks of traditional circumcision, the family of 18-year-old Yongama Boya had him circumcised in hospital before sending him off to the "bush" to complete the rest of his initiation ritual.

But even that did not save him.

Last week, his uncle found the boy in a coma in one of the grass-and-stick shelters at an initiation school in the Qumbu area of Transkei.

And though he ordered water to be warmed, and tried to give it to Yongama to drink, his nephew died before his eyes, without regaining consciousness.

The Mthatha district surgeon who conducted the post-mortem examination listed the immediate cause of death as "consistent with hypothermia".

In the section on the official form for "conditions leading to immediate cause", he wrote: "pulmonary oedema".

In layman's terms, Yongama had pneumonia, and died of exposure.

According to death certificate number B7117961 issued on Friday by the Department of Home Affairs, Yongama died of "unnatural causes".

He was victim number 22 of this year's winter-season crop of Eastern Cape circumcision deaths -- deaths that occur year after year, despite the strenuous efforts of provincial health authorities to stop them.

The causes of those deaths are for the most part roughly evenly split between sepsis, resulting from infected wounds, and dehydration, thanks to the notion that initiates should not drink water for an extended period.

And every year, scores more would-be initiates are admitted to hospital for treatment for problems arising from botched circumcisions, which in the worst cases lead to gangrene and the amputation of the entire penis.

Yongama was a grade 11 pupil at Riverside High School in Mthatha, and, according to his elder brother, Mtsasa, was a good-natured, helpful youth.

...

On June 21 he joined a group of 23 other Hlubi youths at an initiation school in the bush in the Ethwa Location in the Qumbu area.

According to Mtsasa, when the time came for the actual circumcision ceremony, the traditional surgeon saw that Yongama had already been circumcised, and declared, correctly, that he could not re-circumcise him.

Pressured by the leader of the three traditional nurses, or ikhankatha, at the school, the surgeon said he risked losing his registration with the provincial health department if he cut the youth again.

When he persisted in his refusal, the nurse began beating the surgeon and he ran away.

"Then the ikhankatha said, come here, I'm going to circumcise him again, and he circumcised him in front of the other people," Mtsasa said.

After the ceremony, the youths were made to sleep on bare ground under shelters of sticks and grass, even though it was rainy and cold, he said.

"We had bought him a blanket so he could be comfortable," Mtsasa said. "They took away the blanket. He was beaten and not given water or food, I'm told."

In the weeks that followed, Yongama's condition worsened.

When the initiates walked to get food from nearby homesteads, he collapsed repeatedly; when he asked the nurses to call his brother, they refused; when he tried in his weakened state to run away, they caught him and took him back to the school.

When his uncle, Wadana Boya, finally alerted to the boy's plight, went to the school last Friday, he found Yongama, pitifully thin, in a coma.

Yongama died soon after he arrived there.

The nurses, according to Mtsasa, claimed that his death was caused by witchcraft, but the other boys said Yongama had been sick for at least a week before his death.

...
Mtsasa said the Mthatha district surgeon initially put "natural causes" in his post-mortem report.
However, after Mtsasa secured the intervention of the Eastern Cape health department, a second post-mortem was performed by a Port Elizabeth forensic specialist on Wednesday and the cause of death changed to "unnatural".

...
Mvana said he had been told that some of the boys -- including Yongama -- had been forced to sleep in the open, without blankets, despite the bad weather.

Check your bills:

Ryan and Suzanne Kimball were blessed with a baby in October and since then, despite both having good health insurance, have had several bills trickling in for things not completely covered, which they immediately paid.

They recently received another bill from the University of Utah Hospital. Rather than quickly paying it like they have done in the past, they called the hospital to get an itemized bill.

One of the items caused a double-take. It was a charge of $192 for "circumcision."

"Although we didn't keep track of every single test and procedure during the 3-day hospital stay," says Ryan, "we are absolutely positive that our daughter was not circumcised."

The elders are afraid that some men will think that being circumcised is an alternative to using condoms, which will put them at a higher risk of infection, our correspondent says. [A very well-grounded fear.]

But individual members of the community who want to be circumcised are free to do so, the council says.

The Luo Council of Elders is an advisory body whose decisions highly influence the community's beliefs and practices.

The elders say they welcome any measures which will lower the prevalence of HIV/Aids, but are opposed to a campaign to encourage the acceptance of circumcision by the community.

They say the proposal should not be included in the government's policy on HIV/Aids.

The Luo community is mainly found in Kenya's Nyanza and Western Provinces and is Kenya's third largest community.

Studies have suggested that circumcision protects men from contracting HIV and from passing it on to women, and could be used as a weapon in the fight against the spread of HIV/Aids. [This is misleading. No study has shown direct protection to women, only hypotheically, as a result of men being protected from infection by women.]

Initiation schools banned

INITIATION schools will no longer be held in the mountains of the Eastern Cape. Now boys will have to undergo their ritual to manhood in their parents’ backyards.

Transkei traditional leaders made the decision to break from custom and close all mountain schools in a bid to stem the rising mortality of young initiates.

The new arrangement will be introduced between December and January in Transkei, following a decision by a meeting of chiefs from the Transkei area of AmaMpondo aseNyandeni, where the worst mortality figures usually occur.

The provincial Health Department said last week the death toll from initiations had reached 20 for the months of June and July, with scores more initiates admitted to hospitals, some for genital amputation. The death toll excludes last week’s tragedy at Dimbaza where two helpers were burned to death in an initiation hut.

Chief Mangaliso Bokleni of the Gibisela Traditional Council said they had made a painful decision in order to stop boys dying.

“We decided on this harsh solution knowing that no one will accept it but we have no choice.

“The initiates are dying every season and we won’t stand and watch them perish in the mountains,” Bokleni said.

...

But Chief Ngangomhlaba Matanzima, from the Eastern Cape House of Traditional leaders, said closing mountain schools was not the answer.

“Let us bring back ubuntu into our people’s minds so that they can take care of others, including initiates. If the parents care, they won’t send 11-year-olds into the mountains,” Matanzima said.

Health spokesperson Sizwe Kupelo said the onus was on parents to look after their children.

“Most parents contravene the provisions of the Traditional Circumcision Act which regulates the custom in the province.”

At this time last year 24 initiates had died and 41 underwent genital amputations.

53 sick initiates rescued and rushed to hospital

Frank Maponya

At least 53 initiates were rescued from a circumcision school on Wednesday suffering from a series of ailments that included dehydration.

The initiates were part of a large group attending circumcision school at GaChuene outside Lebowakgomo, Limpopo. The victims were removed from the school and admitted to various hospitals around Polokwane.

According to Khosi Vusani Netshimbupfe, chairman of the House of Traditional Leaders in the province, doctors who treated the victims said they were all dehydrated.

At the Cutting edge - male circumcision and HIV

Is mass male circumcision the new big thing in HIV prevention, or is it a risky social experiment that threatens to divert funding from tried and tested interventions?

UNAIDS is careful in its assessment: "Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a 'magic bullet'; it doesn't provide total protection and it doesn't mean people can stop taking the safe sex precautions they were already using."

The caution is a response to the excitement - and debate - triggered by the results of three randomised trials in South Africa, Kenya and Uganda in 2005 and 2006, which seemed to demonstrate that circumcision reduced the risk of HIV infection among men by between 50 percent and 60 percent.

After the slow slog of behaviour-change messaging, here was a simple medical procedure - already widely accepted in many African cultures - that could have a significant impact on HIV acquisition. A broad front of UN agencies, key US-based donors and, recently, African health ministers, have been rallying around an endeavour to make the foreskin history.

DissentBut there are voices of dissent among some social scientists and researchers. They argue that there is not enough incontrovertible evidence to rush to scale-up circumcision (it is still not even certain how a foreskin increases the risk of HIV infection); and why in South Africa, for example, there does not seem to be a significant difference in prevalence between communities that circumcise, and those that do not.

Frustration over the slow headway made by orthodox AIDS programmes has resulted in "a desperation to find something that works, with a growing lobby for biomedical intervention", Prof Peter Aggleton, a researcher at the University of London, told IRIN/PlusNews. "It involves the construction of an agenda that claims to be evidence-based but where the jury is still out."

The danger that men will see circumcision as a quick-fix snip, ignoring public health exhortations to also condomise and reduce partners, is acknowledged by both sides of the debate. But the dissidents question why any potential dilution of the latex message should be risked when condoms provide close to 90 percent protection, and it has been such a struggle in the first place to persuade men to put them on.

For Richard Delate, communications director of the South African health and education programme of Johns Hopkins University, circumcision is simply an additional prevention method. "But we need to give men a choice ... and circumcision provides an entry point where we can engage men to talk about their penises in relation to sexual and reproductive health."

Despite almost a quarter of a century of AIDS awareness programmes, consistent condom use remains frustratingly low, he points out.

But circumcision is not just a medical or cosmetic procedure - for many men it is loaded with significance related to identity and manhood. Social scientists, who feel they have been sidelined in the debate, argue that it is also deeply political, serving as a marker for status, power and social differentiation.

Culture changes

Can a mass rollout work among men in ethnically mixed societies, where foreskins - or their absence - are shorthand for kinship, culture and, almost inevitably, chauvinism? Delate is clear that culture can change: South Africa's Zulus, who used to be circumcised, obeyed a decree by King Shaka sometime in the 19th century and stopped.

"We need to work with traditional structures to explain to them, engaging not just on circumcision but HIV in general," Delate said.

In societies that do cut, traditional rites are imbued with far more meaning than just removing the foreskin: it is an initiation into manhood where cultural and behavioural codes are passed on, which could also have an important bearing on HIV transmission.

Northern Zambia, where circumcision is the norm, has the lowest HIV prevalence in the country. But, according to Mutamba Simapuka of the Maina Soko Military Hospital in the capital, Lusaka, the protective benefits are more than biomedical; young men also receive lessons on fidelity in sexual relationships imparted to initiates.

When northern men migrate to Lusaka, with its looser sexual mores, "their prevalence rates equate with the local population", Simapuka told IRIN/PlusNews.

Traditional methods of cutting, however, are not the safest way to perform the procedure; the point, after all, is for the initiates to prove their fortitude and endurance. Issues of consent are also a problematic area. "To ensure safe and clean operations, male circumcision should only be performed by well-trained practitioners in sanitary settings under conditions of informed consent, confidentiality, proper counseling and safety," is the politically correct advice from UNAIDS.

In the end it boils down to money. Circumcision adds a newly found option for HIV protection, but health services in Africa are already overburdened, under-resourced and struggling to provide even the most basic care. Should circumcision be added to that load?

A concern among dissidents is that new financing might be dangled in front of governments to promote adoption, which would "undermine the existing comprehensive and balanced approach to HIV", according to Aggleton.

The contrary concern is that there will not be enough money. "We will have to look at resourcing to beef up the capacity of health systems, which would have an added benefit [beyond circumcision]," Delate stressed.

More Yemeni women favor female circumcision, shows study

SANA'A, July 04 (Saba)- A recent study has showed a quarter of Yemeni women have been subjected to circumcision and 71.4% of the Yemeni women favored female circumcision while 48% of the Yemeni men support continuing the process of the circumcision.

Among five provinces of the county, Hodeidah and Hadramout provinces were ranked first in the number of the circumcised women by 97.3%, while the prevalence of female genital mutilation in the provinces of Aden and Maharah reached 96.5% in each and in the capital Sana'a has hit 45.5%, according to the study.

The study was conducted by the Centre of Gender Studies and Research in University of Sana'a, UNICEF and Yemen Women Union.

Circumcision and its danger to life

Traditional male circumcision using traditional methods is a dangerous, even life-threatening, rite of passage.

In a study to test the feasibility of an intervention for safe traditional circumcision among Xhosas in the Eastern Cape, Karl Peltzer found weak support for encouraging this practice.

Circumcisions carried out under non-clinical conditions have significant risks of serious adverse events, including death. Among the Xhosas in South Africa, an unsterilised, unwashed blade may be used on a dozen or more initiates in a single session.

Initiates are also significantly dehydrated during their two-week period of seclusion in the belief that this reduces weeping of the wound. And after-care may be done by an attendant with no basic medical training.

The combination of dehydration and septicaemia can result in acute renal failure, gangrene, tetanus or even death. The Eastern Cape provincial department of health recorded 2262 hospital admissions, 115 deaths and 208 genital amputations for circumcisions between 2001 and 2006.

To address this, the Eastern Cape Legislature promulgated a law which regulates traditional male circumcision.

In this intervention study, traditional surgeons and nurses registered with the health department were trained over five days on 10 modules, including safe circumcision, infection control, anatomy, post-operative care, detection, early management of complications and sexual health education. Initiates from initiation schools of the trained surgeons and nurses were examined and interviewed on the second, fourth, seventh and 14th day after circumcision.

The research protocol was reviewed and approved by the ethics committee of the Human Sciences Research Council (HSRC), provincial health department, district health office and traditional authorities .

RESULTS SHOW HIGH RATES OF COMPLICATION
Of the 192 initiates examined on the 14th day after circumcision by a trained clinical nurse, the rates of complications were high: 40 (20,8 percent) had mild delayed wound healing, 31 (16,2 percent) had mild wound infections, 22 (10,5 percent) had mild pain and 20 (10,4 percent) had insufficient skin removed.

Seven days after the circumcision, initiates were asked about the circumcision procedures. Most (85 percent) indicated that the traditional surgeon had been wearing gloves when performing the procedure, and two-thirds (69 percent) of the traditional nurses wore gloves when caring. Further, 53 percent of the initiates reported that they had been circumcised with an assegai (spear) and 47 percent indicated that they had been circumcised with a surgical blade or knife.

EXPECTATIONS ABOUT TRADITIONAL MALE CIRCUMCISION
A total of 126 respondents (70 percent) felt they expected some complication following male circumcision and 57,8 percent expected to stay in the bush for a month, 40 percent less than a month and 11,1 percent for more than a month.

The level of satisfaction among all participants was high; 72,9 percent reported that they were extremely satisfied, 18,8 percent reported that they were quite satisfied, and 5,6 percent reported their dissatisfaction with the appearance of their sex organs.

SEXUAL BEHAVIOUR AND HIV RISK OF INITIATES
Most initiates (88 percent) had sexual intercourse before circumcision. The mean age of first sex was 14,8 percent ranging from 10 to 25 years; 55 percent had been sexually active in the past 12 months; 29 percent reported that they had sexual intercourse with two partners; and 24 (15 percent) had sexual intercourse with three and more sex partners in their lifetime.

Only 38 percent indicated that they had used a condom with their last sexual partner, nine percent were diagnosed with a sexually transmitted disease in the past 12 months, 15 percent used alcohol in the past week and 10 percent indicated that they had sex under the influence of alcohol. Almost all had received Aids training .

Delayed wound healing was found among 21 percent of initiates 14 days after-operation. Most young men (88 percent) were found to be sexually active prior to circumcision and the long period for healing could expose them to elevated risk for HIV infection through an open wound.

TRAINING AND MORE TRAINING
More training is needed in the surgical procedure, the control of sepsis, post-operative wound care, recognition of complications, and when to refer patients to hospital. – Health eNews

RWANDA: Military to lead the way in male circumcision

KIGALI, 3 July 2008 (PlusNews) - The soldiers in the Rwanda Defence Force (RDF) will be the first men to benefit from a government policy to use male circumcision as a tool in the fight against HIV/AIDS, according to senior health officials.

"We will use the military as role models for the rest of the population – they are adult enough to give consent, and if young men see that soldiers are willing to suffer the pain of circumcision, they will also get the courage to do it," said Dr Agnes Binagwaho, executive secretary of Rwanda's national AIDS commission (CNLS). [And how voluntary is the consent a soldier gives?]

"After the military we will concentrate on students and, finally, on the general population; eventually we hope to move on to circumcising new-born babies, as long as research proves that it is advantageous and cost-effective to do so." [So much for "informed consent".]

Unlike many other cultures in the region, Rwandan men and boys are not circumcised as a rite of passage, so it is unclear exactly how many men are circumcised but the number is presumed to be low. Research is underway to determine the percentage of men eligible for circumcision.

Rwanda's Centre for Infectious Disease Control and Prevention, known as TRAC PLUS, is to conduct a 'knowledge, attitude and practice' survey in the army to determine the level of awareness-raising needed, followed by a similar survey among the general population ahead of national rollout of the programme in 2009.

"The survey will ask questions like whether or not they know what circumcision is, whether they can name its advantages or disadvantages, whether they will continue to use condoms following circumcision, and so on. After that, CNLS will be responsible for information, education and communicating the message of circumcision to the public," said Elévanie Nyankesha, HIV prevention coordinator of TRAC PLUS.

"Our national public awareness campaign is due to start in July [2008] and will make it clear that circumcision cannot replace any of our existing prevention strategies – education, abstinence, faithfulness to a single sexual partner and correct and consistent use of condoms," Binagwaho told IRIN/PlusNews.

"People must be made aware that although circumcision is beneficial, there is still a 40 percent risk of HIV transmission, so they must know that it must be used in conjunction with another HIV prevention method, such as condom use," she said. [This shows clearly that she does not understand the statistics.]

HIV prevalence in the RDF is estimated at between two and three percent - slightly lower than the national average of three percent. Intense prevention activities have been carried out since the mid-1990s, and barracks and military hospitals are plastered with billboards and posters urging soldiers to use condoms and be tested for HIV.

"We recently interviewed 70 men at one of the army's VCT [voluntary counselling and testing] centres and, surprisingly, it turned out that 55 of them had already been circumcised either for hygiene reasons, to prevent other diseases or because they believed it would improve their sexual performance," said Dr Charles Murego, director of medical services in the Ministry of Defence.

The circumcision campaign is to be rolled out gradually over a long period, because the 35,000-strong RDF could not afford to have hundreds of men incapacitated at the same time: "We will circumcise, say, 50 soldiers per week – it would be too dangerous to carry out mass circumcision in the army."

The RDF will also encourage former rebels undergoing disarmament, demobilisation and reintegration to undergo circumcision as they prepare to re-enter civilian society.

"We need to train medical staff – doctors, nurses and clinical officers – at our military hospitals, get the necessary equipment and then start the procedures," Murego told IRIN/PlusNews. The RDF has three military hospitals around the country.

Rwanda has more than nine million people, but only one doctor for every 50,000 people and one nurse for every 3,900 people, so increasing the number of medical staff able to perform the procedure is vital to the success of the programme. Nyankesha said doctors who had recently received training in Zambia would start training local practitioners at district level.

The circumcision programme will be funded by, among others, WHO and the UN Children's Fund, and carried out according to United Nations World Health Organisation (WHO) guidelines.

[These figures suggest circumcision may increase the rate of HIV by 1.7% - an increase of 80%, as they would say:]

E Cape circumcision toll rises

Cape Town - Circumcision deaths in the Eastern Cape continue to climb with reports on Thursday of four more fatalities in the Transkei.

The deaths brought the total for the current winter circumcision season to 19, provincial Health Department spokesperson Sizwe Kupelo said.

He said the body of an 18-year-old youth was discovered on Thursday afternoon by department officials and police visiting an illegal school at Rainy village in the Libode area.

Four other boys from the same school were rushed to St Barnabas hospital in Libode town with severe septic wounds.

Kupelo said the traditional surgeon responsible for their circumcisions had been arrested and would be charged with culpable homicide and illegal circumcision.

There was a possibility that the parents of the dead boy could also face charges, because the traditional nurse at the school claimed that he went to the father on three separate occasions to warn that his son's health was deteriorating.

The father allegedly visited the school and declared that his son was "fine".

Kupelo said the department received reports on Thursday of the deaths of three other teenage would-be initiates at illegal schools in the same Western Pondoland area, that happened earlier this week.

"It's so unfortunate," he said. "One death is too many to us.

"We will still continue with our attempts to save lives, and will stop at nothing to achieve that goal."

Though post mortems had not yet been carried out on the latest victims, the usual causes of initiate deaths were septic wounds, or dehydration.

Another boy dies after circumcision

The number of winter circumcision fatalities in the Eastern Cape has risen to 15 following the death of another youth in the Libode area of Transkei, the provincial health department said on Wednesday.

Spokesperson Sizwe Kupelo said the latest death followed an attempt by parents to frustrate the department's efforts to clamp down on an illegal initiation school.

He said police and health officials went to the site of the school at Gxulu village in the early hours of Saturday morning when one youth died there.

They found the site deserted, and community members assured them that all the remaining boys had been taken away by their parents and were safe.

However, Kupelo said, it appeared that they merely re-established the school at a different site.

A second boy died at the new site on Tuesday afternoon.

"This is unacceptable," he said. "People must understand these deaths happen at illegal schools because the whole thing is not properly organised."

Kupelo said autopsies had not yet been carried out, but the usual causes of initiate deaths were gangrene from septic wounds, or dehydration.

He said the department was disturbed by the growing tendency for parents to try to treat initiates' health problems at home.

"It is important for people to raise the alarm with the department because we have the skill, we have the capacity. They are running away from the hospital and it's not going to help."

Earlier this week Kupelo warned that parents who were negligent over their sons' circumcisions would face the full might of the province's Traditional Circumcision Act.

Parents found guilty of contravening the act faced a fine of R1 000 - which coincidentally is the daily cost of hospitalisation for an initiate - or six months in jail.

Over 90 other initiates are being treated in various Eastern Cape hospitals, four of them facing possible genital amputation.

Meanwhile, one Libode chief on Wednesday announced measures to clamp down on illegal circumcision in his area.

Chief Mangaliso Bokleni said his Gibisela traditional council had called an urgent community meeting for Thursday to discuss circumcision problems that have already claimed the life of one initiate in the area.

Bokleni said illegal circumcisions, by unregistered traditional surgeons, were a "big problem" in the area.

Though 18 was the proper age for circumcision, children as young as 11 were being subjected to the practice.

Another problem was that youths did not write their school exams before going to circumcision schools. [So they have to get posthumous certificates...?]

Baby dies during circumcision

Rawalpindi: A baby died in Muslim Town Police Station jurisdiction due
to the loss of blood, as the doctor failed to carry out the
circumcision operation properly. According to sources, the doctor
carried out the operation at the child’s home. A conciliation jirga
will be held to mediate between the child’s father and the doctor.

Real men do it without painkillers

BENON HERBERT OLUKA

Adrenaline runs high as crowds brandishing spears, clubs, flywhisks and fresh tree branches to the skies, surge along the village paths chanting traditional war songs.

Happily they are not on their way to fight an enemy, though the reasons for their testosterone-fuelled excitement are centred on a ritual act of manliness -- the age-old practice of male circumcision, marking the rite of passage from childhood to manhood.

We are visiting the Bugisu (also called Bamasaba) tribe at the foot of Mount Elgon, 256km east of the capital, Kampala, to witness this annual ceremony.

The voices of the initiates -- accompanied by the loud clanging of bells tied to their legs and arms, as well as the brisk pulsations of the zingoma (traditional drums) -- combine to produce a surprisingly harmonious cacophony.

It is these sounds to which the frenzied crowds -- led by a bunch of bare-chested youths -- dance with reckless abandon. Their dance, known in local parlance as kadodi, involves the females twisting their waists and gyrating their backsides, an art that few outside this tribe can muster, while the males do a less artistic but equally energetic prance behind them.

The vigorous dancing raises a cloud of dust that can be seen from hundreds of metres away. The villagers approach a clearing, where a line of mean-looking old men brandishing sharp knives await them. The moment of truth has arrived.

One at a time, the initiates run to the knife-wielding bashebi (local surgeons), jump high and stand firm right before them, grip a stick across their shoulders and look straight to the skies. With astonishing dexterity, each surgeon pulls at the penis of the boy he is assigned to and cuts off the foreskin with the kumubono, as the surgical knife is called. There is nothing symbolic about the pain of this anasthetic-free operation and the crowd falls silent and holds its breath for the 10 seconds the procedure takes. This is the climax of the Imbalu (circumcision).

Among the Bagisu, every boy is supposed to prove his bravery by publicly "facing the knife" without anaesthesia in full view of family and friends. It is hard to watch, this operation, without grimacing or instinctively holding one's own crotch.

Yet the vast majority of the candidates do not even flinch. The trick is said to lie in indianyi and olumbugu. A few hours before knife time, the candidates are given some of these local herbs to steel them; idianyi supposedly makes the candidate develop a yearning for his foreskin to be cut off and olumbugu gives stamina.

Circumcision candidates who endure the pain without showing any signs of weakness are feted as heroes. Those who do otherwise, by crying out or touching the hand of the omushebi, are considered cowards bringing bad luck to the community. They are fined heavily.

A family whose son has shamed the tribe is also asked to perform rituals, slaughtering several animals as part of the cleansing process. Although the rituals are not impossible to perform, no family wants its son to fail as it would make them the laughing stock of the community for years to come.

Sometimes though, bravery comes at a price. Because the omushebi's job is hereditary, handed down from fathers to sons, their training is always done locally. Also, because the kimibono are only sharpened against a special kind of stone, the omushebi's handiwork is not always flawless.

In one incident that I witnessed two years ago at Mutoto Cultural Centre on the outskirts of Mbale town, 16-year-old Ronald Wamimbi had his foreskin cut badly. As he bled profusely, the surgeons tied up the bleeding part with only a thin black string.

Yet there are not many ways around the harsh, proud knife. The option of hospitals and anaesthesia has never been welcome among the Bagisu. Boys circumcised in hospital are labelled cowards and ridiculed by the local community.

But while those who go to hospitals suffer only contempt, it is an even worse offence for a Mugisu boy to shun circumcision altogether. Once the boycotters are discovered, they are circumcised forcefully by members of the community no matter their status in society.

One of the most prominent individuals to have faced the wrath of his kinsmen was one Muduuku, a minister in Uganda's third post-independence government; he should have been circumcised in 1958 but had gone out of the country to study.

On returning to Uganda, Muduuku is said to have declared to his tribesmen that he had been circumcised in hospital. They believed him until 1992. Some things you just cannot hide forever.

Even those who try to cheat culture by dying before they are circumcised do not get away with it. Bugisu tradition demands that before an uncircumcised male who has passed on is buried, his body is propped upright with a pole placed against his back and then circumcised by a retired "surgeon".

I grew up in a community which does not practice circumcision. But when I moved to the Bagisu region to study, I decided I wanted to "face the knife" in the traditional way. This was partly because I was fascinated by the practice and partly because uncircumcised "boys" like me were constantly teased by our peers that we weren't brave enough to do it.

I moved to another part of the country before I could do it, but I still have mixed feelings about my "escape".

Benon Herbert Oluka is a journalist with The EastAfrican newspaper. He lives in Kampala

Uganda: MPs Want Female Circumcision Banned

Madinah Tebajjukira

THE parliamentary food forum has asked the Government to provide funds for the a campaign against female circumcision. Addressing journalists at Parliament on Friday, Bukwo Woman MP Everline Chelangat urged the Government to establish vocational institutions for girls to fight the custom.

Female circumcision, commonly known as female genital mutilation, is practised in Bukwo and Kapchorwa districts.

Girls aged between 10 and 15 are circumcised to determine their maturity.

Chelangat noted a decline in the practice since the United Nations Population Fund launched a campaign against the custom.

She added that the individuals, who were still carrying out female circumcision, do it at night in bushes.

Kangasis County MP Johnson Toskin implored the Government to enact a law that prohibits the tradition. "The Constitution prohibits circumcision of women but it is silent on the punishment for the offenders. We need a stronger law if we are to address this problem," Toskin said.

Four-year-old boy dies during ritual circumcision

“It is a great shock for our hospital,” a senior spokeswoman for the Children’s Republican Hospital of Kazan, Damira Galeyeva said. The death of a four-year-old boy set the whole city in turmoil.

Two four-year-old twin boys, Ilfat and Rifat Zarimovs, were hospitalized for the operation of ritual circumcision. The children were thoroughly examined prior to the operation. Doctors operated Ilfat first, and the operation went through successfully. Rifat died as a result of the operation.

“The examination conducted before the operation did not reveal any contraindications. The doctor who gave the boy the narcosis is a specialist of a higher category who has a very extensive work experience. His qualification does not raise any doubts. Our hospital has up-to-date equipment for anesthesiology and reanimation. The doctors spent 2.5 hours reanimating the boy, but they failed to save him,” Galeyeva said.

The doctor added that one will have to conduct independent expertise to find out the cause of the boy’s death.

“We have received a permission from the Office of the Public Prosecutor to conduct independent expertise. For the time being, there are no official results about the autopsy and conclusions made by forensic experts regarding the cause of death and the chemical composition of the used medications. The results can be received after a detailed investigation,” Damira Galeyeva said.

Incidents of death as a result of circumcision operations are extremely rare. However, they occur.

A month-old boy, the son of the Imam of Moscow’s Historical Mosque, Ramil Sadekov, died as a result of the same operation last year. The boy’s father saw an ad offering circumcision operation services in the street not far from the mosque. The man called the number indicated in the advertisement and invited a ‘doctor’ to perform the traditional ritual on his month-old boy named as Salikh.

The ‘doctor’ came to the imam’s apartment, conducted the procedure and left. It seemed that the operation had been performed successfully, without any complications. However, the boy’s condition started to worsen speedily soon afterwards. The baby was dying for several hours.

“We were cradling the boy throughout the night. At about 5 o’clock in the morning we noticed that the baby started breathing slower than usual. His fingers got cold and turned green,” the parents told the Komsomolskaya Pravda newspaper.

The baby died of blood loss before the ambulance arrived.

Another similar incident took place in Egypt. A 12-year-old girl died as a result of the circumcision operation,

...

Circumcising cultures may circumcise their males either shortly after birth, during childhood, or around puberty

14 die in SAfrica after circumcision, six arrested: official

Fourteen boys died and more than 90 were hospitalised in South Africa's Eastern Cape Province with complications resulting from traditional circumcision rites, an official said Wednesday.

"Fourteen boys died in the last two weeks in the province after they went through the illegal circumcision rite which was badly managed," a spokesman for the province's health department, Sizwe Kupelo, told AFP.

"Ninety-one other boys have been admitted in hospitals following the circumcision and the police have arrested at least six people," he said.

Circumcision is a rite of passage for some South African boys who first go through a lengthy initiation procedure.

Authorities in the province, in conjunction with the police will on Thursday launch "a massive operation" aimed at containing the situation, Kupelo said.

Up to 20,000 boys are believed to be in the bush preparing for the circumcision rite, he added.

"Transkei area in the province is the most affected and that is where we have a serious problem because there is no monitoring of the exercise by traditional elders," Kupelo said.

"The ceremony is officially recognised. But only traditional leaders have a right to perform or supervise the rite. We are not intefering with the custom but our role is to save lives."

In Trankei, elders are not involved in the rite, he said. "Only the youth ... boys terrorise villagers in the night and steal fowls they use for the rite," Kupelo said.

He warned that parents in the province who are negligent over their sons' circumcision could face criminal charges.

"Negligent parents will now be charged with contravening provisions of the Traditional Circumcision Act which regulates the custom," he said.

The law stipulates a 1000 rand (127 dollars/ 80 euros) fine or six months jail term on conviction.

Circumcision: Parents to face prosecution

Eastern Cape parents who are negligent over their sons' circumcision will face the full might of the law, the provincial health department warned on Tuesday.

"Parents should be in the forefront of the fight against unnecessary deaths and complications from traditional circumcision," said department spokesperson Sizwe Kupelo.

"Negligent parents will now be charged for contravening provisions of the Traditional Circumcision Act which regulates the custom in the province."

His warning came as the recorded death toll in the current winter circumcision season in the province climbed to 14.

A total of 91 other initiates were being treated in various hospitals, four of them facing possible genital amputation, he said.

The hospitalisation was costing the province an average of R1 000 an initiate a day, Kupelo said.

In addition, 535 initiates had been treated and discharged at Cecilia Makhiwane hospital in East London.
...

Hotspot areas for the current circumcision problems were Ntabankulu, Libode, Ngqeleni, Bizana, Mthatha and Port St Johns, all in the Transkei.

Kupelo said a team of traditional leaders, police and department officials would visit Pondoland this week to raise awareness of how to curb circumcision deaths and complications. [There's one very easy way....]

The team would also embark on "rescue operation" campaigns to save initiates whose health was at risk.